The prediction of the event in cases of insanity must be the result of
accurate and extensive experience; and even then it will be a matter of
very great uncertainty. The practitioner can only be led to suppose that
patients of a particular description will recover, from knowing, that
under the same circumstances, a certain number have been actually restored
to health.
The practice of an individual, however active and industrious he may be,
is insufficient to accumulate a stock of facts, necessary to form the
ground of a regular and correct prognosis: it is therefore to be wished,
that those who exclusively confine themselves to this department of the
profession, would occasionally communicate to the world the result of
their observations. Physicians attending generally to diseases, have not
been reserved in imparting to the public the amount of their labours and
success; but with regard to this disorder, those who have devoted their
whole attention to its treatment have either been negligent or cautious of
giving information respecting it. Whenever the powers of the mind are
concentrated to one object, we may naturally expect a more rapid progress
in the attainment of knowledge; we have therefore only to lament the want
of observations upon this subject, and endeavour to repair it. The records
of Bethlem Hospital have afforded me some satisfactory information, though
far from the whole of what I wished to obtain. From them and my own
observations the prognosis of this disease is, with great diffidence,
submitted to the reader.
In our own climate women are more frequently affected with insanity than
men. Several persons who superintend private mad-houses have assured me,
that the number of females brought in annually considerably exceeds that
of the males. From the year 1748, to 1794, comprizing a period of
forty-six years, there have been admitted into Bethlem Hospital 4832
women, and 4042 men. The natural processes which women undergo, of
menstruation, parturition, and of preparing nutriment for the infant,
together with the diseases to which they are subject at these periods, and
which are frequently remote causes of insanity, may, perhaps, serve to
explain their greater disposition to this malady. As to the proportion in
which they recover, compared with males, it may be stated, that of 4832
women affected, 1402 were discharged cured; and that of the 4042 men, 1155
recovered. It is proper here to mention that in general we know but little
of what becomes of those who are discharged, a certain number of those
cured occasionally relapse; and some of those who are discharged uncured
afterwards recover: perhaps in the majority of instances, where they
relapse, they are sent back to Bethlem. To give some idea of the number so
readmitted, it may be mentioned, that, during the last two years, there
have been admitted 389 patients, 53 of whom had at some former time been
in the house. There are such a variety of circumstances, which, supposing
they did relapse, might prevent them from returning, that it can only be
stated, with confidence, that within twelve months (the time allowed as a
trial of cure) so many have been discharged perfectly well.
To shew how frequently insanity supervenes on parturition, it may be
remarked, that, from the year 1784 to 1794 inclusive, 80 patients have
been admitted, whose disorder shortly followed the puerperal state. Women
affected from this cause recover in a larger proportion than patients of
any other description of the same age. Of these 80, 50 have perfectly
recovered. The first symptom of the approach of this disease, after
delivery, is want of sleep; the milk is afterwards secreted in less
quantity, and, when the mind becomes more violently disordered, it is
totally suppressed.
From whatever cause this disease may be produced in women, it is
considered as very unfavourable to recovery, if they are worse at the
period of menstruation, or have their catamenia in very small or
immoderate quantities.
At the first attack of the disease, and for some months afterwards, during
its continuance, females most commonly labour under amenorrhoea. The
natural and healthy return of this discharge generally precedes
convalescence.
From the following statement it will be seen, that insane persons recover
in proportion to their youth, and that as they advance in years, the
disease is less frequently cured. It comprizes a period of about ten
years, viz. from 1784 to 1794. In the first column the age is noticed, in
the second the number of patients admitted; the third contains the number
cured; the fourth those who were discharged not cured.
Age between Number admitted. Number discharged Number discharged
cured. uncured.
10 and 20 113 78 35
20 and 30 488 200 288
30 and 40 527 180 347
40 and 50 362 87 275
50 and 60 143 25 118
60 and 70 31 4 27
----- ----- -----
1664 574 1090
Total admitted. Total cured. Total uncured.
From this table it will be seen, that when the disease attacks persons
advanced in life, the prospect of recovery is but small.
From the very rare instances of complete cure, or durable amendment, among
the class of patients deemed incurable, as well as from the infrequent
recovery of those who have been admitted, after the complaint has been of
more than twelve months standing, I am led to conclude, that the chance of
cure is less, in proportion to the length of time which the disorder shall
have continued.
Although patients, who have been affected with insanity more than a year,
are not admissible into the hospital, to continue there for the usual time
of trial for cure, namely, a twelvemonth, yet, at the discretion of the
committee, they may be received into it from Lady-day to Michaelmas, at
which latter period they are removed. In the course of the last ten years,
fifty-six patients of this description have been received, of whom only
one has been discharged cured. This patient, who was a woman, has since
relapsed twice, and is, at present, in the hospital.
When the reader contrasts the preceding statement with the account
recorded in the report of the committee, appointed to examine the
physicians who have attended his majesty, &c. he will either be inclined
to deplore the unskilfulness or mismanagement which has prevailed among
those medical persons who have directed the treatment of mania in the
largest public institution, in this kingdom, of its kind, compared with
the success which has attended the private practice of an individual; or,
_to require some other evidence, than the bare assertions of the man
pretending to have performed such cures_[5]. It was deposed by that
reverend and celebrated physician, that of patients placed under his care
within three months after the attack of the disease, nine out of ten had
recovered[6]; and also that the age was of no signification, unless the
patient had been afflicted before with the same malady[7].
How little soever I might be disposed to doubt such a bold, unprecedented,
and marvellous account, yet, I must acknowledge, that my mind would have
been much more satisfied as to the truth of that assertion, had it been
plausibly made out, or had the circumstances been otherwise than feebly
recollected by that very successful practitioner. Medicine has generally
been esteemed a progressive science, in which its professors have
confessed themselves indebted to great preparatory study, and long
subsequent experience, for the knowledge they have acquired; but in the
case to which we are now alluding, the outset of the doctor's practice was
marked with such splendid success, that time and observation have been
unable to increase it.
This astonishing number of cures has been effected by the vigorous agency
of remedies, which others have not hitherto been so fortunate as to
discover; by remedies which, when remote causes have been operating for
twenty-seven years, such as weighty business, severe exercise, too great
abstemiousness and little rest, are possessed of adequate power directly
to _meet and counteract_ such causes[8].
It will be seen by the table that a greater number of patients have been
admitted between the age of thirty and forty, than during any other equal
period of life. There may be some reasons assigned for the increased
proportion of insane persons at this age.
Although I have made no exact calculation, yet, from a great number of
cases, it appears to be the time, when the hereditary disposition is most
frequently called into action; or, to speak more plainly, it is that stage
of life when persons, whose families have been insane, are most liable to
become mad. If it can be made to appear, that at this period people are
more subject to be acted upon by the remote causes of the disease, or that
a greater number of such causes are then applied, we may be enabled
satisfactorily to explain it. At this age people are generally established
in their different occupations, are married, and have families; their
habits are more strongly formed, and the interruptions of them are,
consequently, attended with greater anxiety and regret. Under these
circumstances, they feel the misfortunes of life more exquisitely.
Adversity does not depress the individual for himself alone, but as
involving his partner and his offspring in wretchedness and ruin. In
youth, we feel desirous only of present good; at the middle age, we
become more provident and anxious for the future; the mind assumes a
serious character, and religion, as it is justly or improperly impressed,
imparts comfort, or excites apprehension and terror.
By misfortunes the habits of intoxication are readily formed. Those, who
in their youth have shaken off calamity as a superficial incumbrance, at
the middle age feel it corrode and penetrate: and when fermented liquors
have once dispelled the gloom of despondency, and taught the mind either
to excite a temporary assemblage of cheerful scenes, or to disdain the
terror of impending misery, it is natural to recur to the same, though
destructive cause, to reproduce the effect.
Patients, who are in a furious state, recover in a larger proportion than
those who are depressed and melancholick. An hundred violent, and the same
number of melancholick cases were selected. Of the former, sixty-two were
discharged well; of the latter, only twenty-seven. When the furious state
is succeeded by melancholy, and after this shall have continued a short
time, the violent paroxysm returns, the hope of recovery is very slight.
Indeed, whenever these states of the disease frequently change, such
alternation may be considered as unfavourable.
Where the complaint has been induced from remote physical causes, the
proportion of those who recover is considerably greater, than where it has
arisen from causes of a moral nature. In those instances where insanity
has been produced by a train of unavoidable misfortunes, as where the
father of a large family, with the most laborious exertions, ineffectually
struggles to maintain it, the number who recover is very small indeed.
Paralytic affections are a much more frequent cause of insanity than has
been commonly supposed. In those affected from this cause, we are, on
enquiry, enabled to trace a sudden affection, or fit, to have preceded the
disease. These patients usually bear marks of such affection, independent
of their insanity: the speech is impeded, and the mouth drawn aside; an
arm, or leg, is more or less deprived of its capacity of being moved by
the will: and in by far the greatest number of these cases the memory is
particularly affected. Very few of these cases have received any benefit
in the hospital; and from the enquiries I have been able to make at the
private houses, where they have been afterwards confined, it has appeared,
that they have either died suddenly from apoplexy, or have had repeated
fits, from the effects of which they have sunk into a stupid state, and
have gradually dwindled away.
When the natural small-pox attacks insane persons, it most commonly proves
fatal.
When insanity supervenes on epilepsy, of where the latter disease is
induced by insanity, a cure is very seldom effected: from my own
observation, I do not recollect a single case of recovery.
When patients during their convalescence become more corpulent than they
were before, it is a favourable symptom; and, as far as I have remarked,
such persons have very seldom relapsed.